Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Monday, October 31, 2011

For the second time in two months, bizarre weather has knocked out my electricity supply, and apparently it's going to take a week to get it back once again. Big deal, right? People got along just fine without electricity for a million years or whatever (depending on when you want to start calling the critters people), I can certainly make it for one week.

Think about it -- electricity delivered to the home from central generating stations has been the general way of life in the United States for only about 100 years. It didn't make it to rural areas until much later -- the Rural Electrification Act was passed in 1936. I'm reading Daniel Yergin's biography of petroleum (I think that's a fair description), The Prize, and you may not have thought about this before, but John D. Rockefeller grew rich selling kerosene for lighting. Petroleum burst onto the scene as a substitute for tallow candles and whale oil. Powering engines came, including electrical generators, came much later.

In this brief historical moment electricity has completed transformed our society, and our daily lives such that it is indispensable. I happen to have heat without electricity, because I have a Vermont Castings Defiant wood burning stove, but I don't have running water, and I'm reduced to reading by candlelight. No way to take a shower, vacuum the floor, charge my computer or cell phone, watch television -- getting news of the outside world, if I didn't have a nice well-powered office to go to, would require purchasing a bunch of wood pulp with ink on it. I can cook a meal on top of the wood stove -- and I did, actually, on Saturday. But I couldn't wash the dishes. If I decide to tough it out, I'll have to carry a bucket down to the stream to haul up water, and heat it on the stove top, all by candle light since it's basically dark shortly after I get home.

Well yeah, that's what people used to do. They must have been miserable, right?

Friday, October 28, 2011

of AIDS denialism. A multitude of Brits has completed a prospective cohort study of people living with HIV from 1996 through 2008. This is the most powerful, persuasive study design possible. It's Da Bomb of studies of HIV treatment. 1996 is basically the year when effect antiretroviral treatment became available. Here's the bottom line:

1) Life expectancy at age 20 of people living with HIV increased from 30 to 45.8 years over the period.

2) Life expectancy at age 20 was 37.9 for people who started therapy with CD4+ cell count less than 100; for people who started therapy with CD4+ count above 200, it was 53.4, getting up there pretty close to normal.

This "life expectancy" number is artificial, of course - I've explained it here before. But it's the best estimate of what a person age 20 can expect based on the experience we have with people of all ages with HIV since 1996. For those who don't know, CD4+ cells are a particular type of immune system cell, also called "helper T cells," that HIV preferentially infects and destroys. It's the loss of those cells that causes the immunodeficiency characteristic of AIDS.

So this is what we keep telling the AIDS deniers: if you have HIV, and you don't take the pills, you get sick and die. Even if you take the pills starting fairly late, after your T-cells are depleted, the numbers will come back but you aren't likely to live such a long healthy life, probably because you no longer have the variety of T-cells needed to confront the variety of pathogens you're likely to experience, and possibly because of other damage as well. But if you take the pills, take them regularly, and stick with it, you can look forward to a reasonable life span. Fact. Done.

That doesn't mean it's okay to get HIV. The pills have side effects, they're expensive, and you won't likely live as long or be as healthy as you would be without the infection. You'll do okay, but you really don't want it.

That said, and given that prevention is still the far better alternative, this does show that what I learned in school about the fairly small contribution of medical intervention to health and longevity is no longer true. Medicine has gotten better. It can pay real benefits. It's still true that it's even more important for people to have good diets, maintain healthy weight, not be assaulted by environmental contaminants or violence or poverty, not smoke or otherwise poison themselves, and so on. And it's also still true that too much medical intervention can be as bad or worse than too little.

But even if you're lucky enough to have all the good stuff and do all the right stuff, you're still gonna want a doctor.

And that's why we need universal access to high quality, evidence based medicine. And that's why we need universal, comprehensive, single payer national health care.

Thursday, October 27, 2011

is in a hospital. Hospitals are very dangerous places for several reasons. The most obvious is that there are a lot of debilitated people there with tubes going into their orifices, and often extra holes with extra tubes, that are full of all kinds of nasty bugs that eat antibiotics for breakfast, and then eat people for lunch.

But that's not the only reason. I'll pass briefly over the risk entailed by being in the clutches of doctors who are often overeager to do really radical stuff to you, although I happen to think that's quite dangerous. As Covinsky and colleagues discuss in JAMA, an extraordinarily high percentage of older folks who are hospitalized for one reason or another leave the hospital with brand new disabilities having nothing specifically to do with the original reason for hospitalization. Quite often, they never make it home again. Among the reasons:

Excessive confinement to bed. This can happen due to inappropriate bed rest orders, or because they are essentially tied to the bed by a urinary catheter or IV line. If you can walk, dress yourself, make it to the toilet, etc. when you enter the hospital, you should insist on keeping on doing it. When people who are already frail become inactive for even a couple of days, they often can't get their strength back.

Poor nutrition. Again, people may be placed on restrictive diets inappropriately, but they also may just find it very hard to eat the swill placed in front of them. And, as with the above, when you lose strength due to a bout of malnutrition, if you're getting on in years, it may be hard to get it back.

Falls. The hospital is an unfamiliar environment and believe it or not, regular hospital wards aren't necessarily set up so as to be safe for people prone to falling -- there's a lot of weird furniture on rollers, slippery floors, often the odd piece of paper or linen lying on the floor, not necessarily railings where they should be, etc.

Delirium. The environment is bizarre, noisy, chaotic. People may be drugged or sleep deprived. The result is often loss of contact with reality. Sometimes people never fully recover their cognitive chops.

So . . .

A) Try not to go there, and deal with issues on an outpatient basis if at all possible.

B) If you do have to go there, as I say, be feisty and a pain in the ass and insist on getting out of bed, getting dressed, getting yourself to the loo, keeping to your usual routine of newspapers and crosswords or whatever, as much as you possibly can. Eat. Don't take any crap.

Wednesday, October 26, 2011

I've been hearing ads on National Pubic Radio - oh excuse me, not ads, "underwriting" -- for this new film that claims the Earl of Oxford wrote Shakespeare's plays. Here's Joe Romm comparing this absurd nonsense to climate change denialism. I came across it after a visit to Seth Kalichman's blog, where a commenter issues a veiled death threat because Dr. K maintains that HIV causes disease. As you may have noticed, it is now an official requirement for Republican candidates for office to deny evolution, anthropogenic climate change, and the toxic effects of air and water pollution.

Many questions are legitimately controversial and every once in a while, some pretty well-settled beliefs get overturned. But that's actually less common than it used to be, because unlike folks in the past, we have a vast and growing accumulated store of knowledge on which to build our conclusions, ever better methods of observing and measuring, and more powerful deductive tools and ways of testing hypotheses. We actually do know more than people knew in the past. So yeah, Galileo was right and the prevailing belief was wrong but guess what? There's zero chance Galileo will be overturned and we'll find out the earth is at the center of the universe after all.

The same goes for evolution. We know that the broad outlines of evolutionary theory are correct and that life on earth diversified over billions of years from a common ancestor. It's just a fact, like the earth going around the sun. It's been proved beyond any shadow of a doubt by an overwhelming body of evidence. Same with HIV and AIDS. Everybody who has had anything to do with HIV care knows that if you give people who are at death's door from AIDS anti-retroviral drugs, they get better. People who weigh 80 pounds, whose bodies are wracked by fungal infections and bizarre viruses, who vomit up everything they swallow, suddenly get up off their death beds and start chowing down and dancing the cha cha. They stop taking the drugs, they get sick again. They take the drugs again, they get better again. QED.

And so on. Homeopathy. Vaccines cause autism. Dick Cheney masterminded the 9/11 attacks.* Yet these people are absolutely beyond hope of convincing. No possible evidence or argument could sway them. I'm proud to say that I've changed my mind on quite a few issues after studying the evidence. But it seems a badge of honor right now for people to refuse to do so and not only to hang on fiercely to nonsensical beliefs, but to demonize and threaten people who are rational. See Rick Perry claiming that the entire enterprise of climate science is a conspiracy to steal grant funding by falsifying data, and the Virginia AG trying to prosecute Michael Mann.

And the corporate media, as we well know, is resolutely committed to avoiding sorting out truth from falsehood at all costs. "Shape of the Earth: Views Differ," as Paul Krugman imagined the headline. Our civilization is in peril. I'm at my wit's end.

* Yes, the Bush administration failed to act on information urgently provided to "president" Bush. There's probably a lot more we should know about the whole thing. But we know who proactively did it and why the buildings fell down.

Tuesday, October 25, 2011

Lawrence J. Schneiderman offers up plenty of most excellent zingers regarding our cultural blindness about the nature of medical services and the ineluctable limits thereon. It's the sort of thing I keep saying here but he's more famous. A sampling of the good bits:

Throughout their exertions, members of Congress have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination as to what health outcomes should receive priority in a just society. "Priority in a just society”—those five words are encompassed and eclipsed by one word that was excoriated or indignantly tossed aside: rationing.

We will have to make tough choices, of course, but the choices will be based not on capricious gated communities of eligibility for limited, expensive, high-technology, life-sustaining treatments—for example, simply by reaching age 65 one suddenly becomes entitled to Medicare, which will provide substantial coverage for all sorts of organ transplants but sadly not a penny's help with walking, eating, bathing, and other daily tasks by qualified home health care workers, or even by family members who may have to give up their job to attend to these far more common elderly needs. These costs are a major source of bankruptcy and can amount to 10% of household income, causing severe economic, social, and psychological burdens on caregivers. Recognizing that there has to be a limit to the otherwise boundless demands that can be made on medical care, we must accept that medicine cannot serve every personal need, desire and good. Everyone is not entitled to everything. Everyone is entitled to a decent minimum level of medical care.

[T]he R-word, rationing, the proverbial third rail in the halls of Congress: Touch it and you’re dead. At least your legislation will be; witness the instant defeat of the mild effort to have Medicare reimburse physicians’ time to discuss end-of-life treatment alternatives, including advance directives. “Death panels,” shouted the opposition. “Pulling the plug on grandma!” “We cannot have rationing!” declare politicians who complacently enjoy their own medical insurance and overlook the irrational rationing that takes place all around them. Yet everyone who spends any amount of time thinking about this problem knows that rationing is ongoing and inevitable. As noted even in that champion of the libertarian free market, The Economist, “Every health system rations in some way or other; the demand for health care is always greater than the resources available. The question is whether rationing is done openly and as sensibly as possible—or done implicitly, through murky pricing, bureaucratic fiat or denial of care."

Alas, his solution I fear is too full of fuzzy logic and complex ethical judgments to advance the cause. Indeed, after reading the article carefully, twice, I'm not sure I understand it, and I don't consider myself a dolt. He attempts to apply a utilitarian ethic that weighs a combination of urgency of need, personal functional status, and social benefit. He tries to wiggle out of the accusation that his proposal values people's lives and health differently depending on somebody's evaluation of their relative worth to society, but alas, as far as I can tell, he wiggles futilely. Such judgments do appear to be lurking in the weeds of his garden, and he offers no clear and consistent way of making them, beyond a call for "transparency" and an appeal process. Not going to happen.

But, we sure as hell need to do something. The Republican solution is to champion injustice, exploitation, expropriation, waste and abuse. The Democratic solution is to wimp out and do nothing meaningful - including being too frightened even to make a clear statement of the problem. At least Schneiderman tries to give us that.

Monday, October 24, 2011

That is our self-awareness, and the psychological and social complexity which it contemplates. This makes being human extraordinarily interesting, but sometimes unendurable. As Christabel Owens and others note in their very interesting paper, Recognising and responding to suicidal crisis within family and social networks (British spelling there, not a mistake), almost one million people take their own lives every year.

Suicide is a surprisingly significant cause of death, but it's obviously a far greater tragedy than most more prevalent causes. It takes the lives of many young people, and it often leaves survivors feeling guilt as well as the pain of loss -- not to mention the pain the decedent must have been feeling, often completely unknown to others, or misunderstood.

Owens et al interviewed the loved ones of people who had killed themselves, and they find much that may not only be of practical help to people in similar situations, but also enriches our understanding of our shared condition. It seems to many of the survivors that the deceased had great difficulty, for various reasons, in communicating his or her distress; that the ambivalence that possibly suicidal people often feel is likely to be interpreted as meaning that the suicidal intent is not to be taken seriously; that it is often difficult for us to understand the inner lives even of people with whom we are intimate; that people do not want to be intrusive or seem to compromise the autonomy of loved ones; and that they also do not want to violate privacy or disrupt other people's relationships.

In fact, there is no harm in asking someone who seems deeply distressed whether they have contemplated suicide, or in inquiring about ambivalent or conflicting signals. There is no harm in encouraging people to get help. At the same time, people should not punish themselves with guilt for missing the signs which, as it turns out, can be difficult to interpret and act upon. I hope that this research, and other information which is available (e.g., American Foundation for Suicide Prevention) will reach more people.

As far as I know, only we, among the sentient creatures, feel our way in the world keenly enough that continuing sometimes becomes intolerable. Let's try to make the world a little less cold.

Thursday, October 20, 2011

I'm writing just a few minutes after Al Jazeera posted video conclusively proving that Muammar Gaddafi has been killed by revolutionary fighters. (There's no particular sense linking to the video, which is ephemera, since the fact of his death will soon be generally accepted and you don't need to look at that anyway. However, here's the link to the Al Jazeera home page for your bookmarks.)

As readers know who have checked out my side bar, another of my blogospheric projects has been helping to document and excoriate the illegal war of aggression waged by the U.S. in Iraq, and more recently the pointless, destructive ongoing occupation and aggression in Afghanistan. I was for many years on the Steering Committee of Boston Mobilization for Survival and I helped organize demonstrations in Washington and Boston against Reagan era intervention in Central America and against the Iraq atrocity. I've helped to organize and promote talks by everyone from Noam Chomsky to Howard Zinn to Cynthia Enloe to Fr. Robert Drinan, condemning U.S. imperialism and militarism. I have a drawer full of anti-war memorabilia.

But sometimes these hard cases come along. I found myself at odds with much of the anti-war community in the Boston area over the U.S. intervention in the ethnic conflict in the former Yugoslavia. In fact it was so contentious -- and back then I wasn't very good at managing conflict -- that it caused a major falling out between me and some old friends. Specifically, I saw the air campaign to protect the Kosovars from the genocidal campaign of Slobodan Milosevic not as an imperialist aggression but as a moral imperative. I felt that my comrades were reacting reflexively based on our long history of opposing proxy wars during the Cold War and campaigns to protect U.S. corporate interests in Latin America. This was really different. The memory of our failure to stop the Rwandan genocide was still fresh. I could not see how, when we had the power to stop something similar from happening, we could just sit and watch.

Yes, there were innocent people who died from U.S. bombs. But many more would have died had we not acted. And there was no evident U.S. interest in the intervention other than promoting stability and the preservation of international norms in Europe. I could discern no important ulterior motives.

The Libyan situation is more difficult to characterize. Gaddafi, for all his crimes, was the internationally recognized head of state and he was, without a doubt, putting down an insurrection. That's the legal fact. The moral fact is that his rule was illegitimate and was recognized by the U.S. and European powers out of purely cynical motives. To be sure, there are others like him who we continue to stand by. But as purely pragmatic matter, there was an opportunity here, because there was a massive, adequately led and reasonably well-armed uprising that could depose him if NATO acted as its air force; and there was a quite broad international consensus for action, including UN and Arab League cover, if not exactly support. Remember the horror that ensued when George Bush the First encouraged the Shiites in southern Iraq to rise up, and then failed to support them?

The Libyan civil war has resulted in the deaths of many innocent people. There's no telling how many but certainly the number is above 1,000. Many more have been displaced and are homeless. We don't know what will ensue, whether Libya will ultimately have a more just and open society. But I just couldn't decide that I needed to condemn the intervention. I believe there is a morally respectable case for it. What do you think?

As you may recall from previous episodes, the FDA sometimes requires medical device makers to conduct post-marketing safety studies of medical devices as a condition of approval. The only problem is, this "requirement" is not, in fact, a requirement. The companies often don't do it, or they sort of kind of start the studies but never complete them, and the FDA doesn't do anything about it. As Kuehn puts it, "Critics argue that tougher sanctions from the agency or greater collaboration from government agencies to ensure collection of the necessary data may help resolve this problem."

My only comment on that is, "Well, duhhh."

However, what I'd really like to discuss here is the specific issue of silicone breast implants. The drama around this was pretty well publicized a few years back. Concerns about silicone leaking into the body and causing disease led to a 14 year ban on plastic boobs but the FDA approved two products in 2006, with the condition that the companies conduct post marketing safety studies. They were required to follow at least 40,000 women for 10 years, but after 3 years, the follow-up rates are only 60.2% for one company and 21.8% for the other. At this rate, the FDA concludes, they won't have enough statistical power to detect uncommon, but possibly very serious, outcomes.

Okay, that's bad, but here's what we already know:

There are frequent "local" complications such as implants rupturing or contracting into a hard mass, wrinkling, scarring, pain, asymmetry and infection. Remember that the only point of these implants is cosmetic.

20-40% of women who got boob jobs for cosmetic purposes had them removed within 10 years; 40-70% of breast reconstruction patients had them removed.

There appears to be a small increase in the risk of anaplastic large cell lymphoma. It's rare, but if it does happen, you'll be lucky to live 5 years.

Ladies, listen up. Some guys like big bazongas, it's true. But believe it or not, some guys, probably just as many, don't, even if they aren't supposed to admit it. I don't know, given the above facts -- plus what we don't know due to the companies figuring that what you don't know can't hurt them -- whether these really ought to be approved for sale. Personal choice and all that. But knowing what you know now, is this something you really want to do? Just to appeal to a sub-set of men who happen to have a specific fetish and don't love you for your beautiful mind after all? Just askin'.

Climate change poses an immediate, growing and grave threat to the health and security of people in both developed and developing countries around the globe.

Climate change leads to more frequent and extreme weather events and to conditions that favour the spread of infectious diseases. Rising sea levels, floods and droughts cause loss of habitat, water and food shortages, and threats to livelihood. These trigger conflict within and between countries. Humanitarian crises will further burden military resources through the need for rescue missions and aid. Mass migration will also increase, triggered by both environmental stress and conflict, thus leading to serious further security issues. It will often not be possible to adapt meaningfully to these changes, and the economic cost will be enormous. As in medicine, prevention is the best solution.

Action to tackle climate change not only reduces the risks to our environment and global stability but also offers significant health co-benefits.[i] Changes in power generation improve air quality. Modest life style changes – such as increasing physical activity through walking and cycling - will cut rates of heart disease and stroke, obesity, diabetes, breast cancer, dementia and depressive illness. Climate change mitigation policies would thus significantly cut rates of preventable death and disability for hundreds of millions of people around the world.

Oh, I see. Of course, this won't do anything to increase doctors' incomes. So there's no reason for the AMA to get involved.

Monday, October 17, 2011

Inspired by RA's comment on the previous post, I would say it's still an open question what health status and longevity will be like in rich countries like the U.S. of A. as the 21st Century staggers on. It's already conventional wisdom in the public health community that life expectancy will decline a bit because of the obesity epidemic. It's very difficult to say whether there is any signal from chemical exposures, such as pesticides and industrial effluent, for the mildly paradoxical reason that people are living longer. If these exposures do increase the risk of cancer and metabolic diseases, we can't exactly tell because these diseases are also associated with age, and it used to be that not a lot of people lived long enough to get them. Also, obesity is a risk factor, while smoking rates have been declining. Etc. In other words, hard to sort all that out.

But, in fact, probably the biggest threat to our health as a people is the rise in inequality. Inequality makes us sick. If we can't provide decent opportunity, security, and a supportive social environment for everyone, then we won't be as healthy and we won't live as long. Yes, clean air, clean water, a healthful food supply, all matter. But only at the margins. The impact of these sorts of environmental insults on people who are well nourished, psychologically whole, and well cared for, is much less than on people who are otherwise disadvantaged. And disadvantage reproduces itself throughout and across communities, and down through time and generations.

As for the long-term human population, however, it doesn't matter what happens to people past child bearing age. If everybody dropped dead at age 50, it would have no effect on the number of children born in 2050. (At least not directly. It would reduce pressure on resources, obviously, in the interim, but might prove economically costly because we'd lose all those experienced, wise people such as myself.) And actually, the male population barely matters either. The only question is how many girls survive through their reproductive years, and how many babies they have, and how many of those girl babies in turn survive. So unless we want girl babies to die, women need to have fewer children. That's the bottom line.

Sunday, October 16, 2011

That's the widely accepted mid-range forecast for the human population in 2050, with the number expected to stabilize at about 10 billion by century's end. The stabilization is expected to happen because of the long-term trend toward declining birth rates as societies become more prosperous, the status of women rises, and infant and child mortality declines.

As Robert Engelman discusses at Climate Progress, all this projecting assumes no increase in the death rate. In fact it assumes continuing increases in life expectancy and declines in early mortality. People are very reluctant to go there, it seems, but what if it doesn't happen that way?

Engelman points to climate change and rising sea levels. He doesn't have much to say about the possibility of emerging infectious diseases, which worries some people quite a lot. He also apparently wrote before news of an analysis, about to appear in the journal Nature, which finds it might be barely possible to feed 9 billion people, but only if humanity makes several major changes, none of which are happening now. The most important is for people to eat less meat. Most cropland is devoted to growing animal feed, which turns into about 1/8th as much human food. However, the current trend is the opposite: people are eating more and more meat, particularly as China becomes more affluent.

But we don't have to wait until 2050 to know that we have a problem. We have a problem right now. As John Schoen reported earlier this year, the global food supply is stretched to the limit. Rising food prices contributed to the social unrest that created the Arab Spring, and the UN now expects food prices to remain high forever, basically. Reserves are at the lowest level in 30 years and still falling. Weather anomalies as well as rising demand, and diversion of crops to biofuels, are behind the shortages. All of that is just going to get worse.

So no, there can't be 9 billion people. That can't happen. It can not happen the hard way, or it can not happen the easy way. Unfortunately, "Christians" who oppose contraceptive services want to make sure it happens the hard way, because you know, Jesus wants children to starve. Meanwhile, however, please eat less meat.

What I do believe is not simple to explain. To begin with, there are various senses of "belief." I could say that I believe Shakespeare was a great writer, for example. One true fact about me is that I am an admirer of Shakespeare. Some people are either unfamiliar with Shakespeare's work, or don't care for it as much as I do. Our lack of shared belief in this case does not entail any contradiction. You can feel any way you want about Shakespeare as a writer, including having no opinion at all, without in any way calling into question my feelings about the Bard.

I also believe that the plays were written by the son of a local official and glove maker from Stratford-upon-Avon. Some people don't believe that. Therein does indeed lie a contradiction. We cannot both be right. This is what is called a truth claim as opposed to a personal preference or taste. However, we might have these opposing beliefs while sharing pretty similar criteria for evaluating truth claims. Perhaps we have not seen all of the same evidence, or make different judgments about probabilities. We might argue passionately but the fundamental nature of reality is not at stake.

Next, I believe that Shakespeare was the descendant of creatures that lived in Africa around 6 million years ago whose descendants also include chimpanzees. You might believe that he is the descendant of people created magically from dust by a supernatural being less than 10,000 years ago. These opposing claims cannot possibly be based on similar criteria for judging truth, because the kinds of evidence that exist for them are completely different. The evidence for my conclusion consists of an overwhelming body of observations about the remains of ancient creatures preserved in rock; the biology of chimpanzees, humans, and other creatures including their DNA and everything having to do with genes and gene expression; geology; cosmology; and observations about the distribution of all sorts of creatures around the planet and their interactions with their environments and in many cases, their observable evolutionary change over time. And more. It's based on a broad, complex picture of reality built up painstakingly, piece by piece, from evidence.

The supernatural being making the man from dust, however, is based entirely on the contents of an ancient book written by people who had no evidence whatsoever for the story they told. They were just imagining it. And it is full of both internal contradictions and contradictions with observable reality. Believing such a story is just silly. We know more than they did because we have been studying the world, and writing down our observations, and passing them on to the next generation, so each knows more than the last.

So the question is not why am I an atheist. I'm an atheist because there is no meaningful evidence whatsoever for the existence of God; and because the concept of God is both internally contradictory and contrary to readily observable reality. That isn't really even worth an essay. I find it trivially obvious. The question is why so many people cling fiercely to silly stories. That requires an essay.

Thursday, October 13, 2011

In the 1930s, the last times as hard as what we're in now, the state stepped in to write a new contract between capital and labor that saved capitalism, whether the plutocrats whose greed caused the Depression and the devastation of the working class appreciated it or not. Today, we're back where we were in 1929, and people are finally taking to the streets in anger and desperation -- but with an astonishingly sunny disposition about the whole thing, I must say.

(For those of you who haven't seen it yet, former Schtickdreck Henry Blodgett, who helped pump up the Internet bubble, is now telling it like it is. Don't miss it. I believe I recently mentioned that inequality in the U.S. is now making Third World kleptocracies look benign, as Blodgett's colleague Gus Lubin illustrates.)

However, the response of the GOP (Grand Old Plutocracy) is to propose raising taxes on the bottom half of income earners in the interest of "fairness," while further cutting taxes on the ultra-wealthy -- which are by the way at the lowest level since 1930. That ought to seem really weird, but in fact the polling numbers right now show Plutocracy Party candidates running neck and neck with the president, who has cut taxes on workers and for that matter middle income professionals, and wants to raise taxes on the wealthy, while spending money to create jobs and pull the economy out of the quicksand -- all of which makes him a socialist who hates America.

There's false consciousness, and then there's insanity. The problem is that the corporate media refuse to explain any of this clearly, and instead choke the public square with obfuscating smoke. The 6 trillion dollar question is what's going to happen when those folks out in the streets just get mocked by the corporate media, their plight belittled by the political class, and they're still out of work, and it just keeps getting worse.

Tuesday, October 11, 2011

We should probably distinguish between two components of the so-called dietary supplements industry. Component number one, which gets a continual trashing at such worthy locations as Respectful Insolence and Science Based Medicine (which are not wholly separate entities, but that's by the way), is the "herbal remedy" or more accurately snake oil industry. This consists of companies that sell worthless products which they insinuate will cure your ills, but don't need to have any actual evidence because Congress has forbidden the FDA from regulating anything that's called a "dietary supplement" until and unless it comes to their attention that the stuff is actually killing or harming people, and they can prove it.

These are the people who claim to have the secret knowledge that "they," meaning mostly the pharmaceutical industry, don't want you to know about. Why these evildoers can't be prosecuted for fraud is unclear to me. Homeopathic remedies are in that class but so are echinacea, saw palmetto, etc.

Then there are products that really are dietary supplements, in the sense that they contain concentrated amounts of nutrients, such as vitamins and minerals, that we really do need in our diets. The purveyors of these products are usually more circumspect in their claims, partly because they are often big mainstream corporations some of which also produce FDA-approved pharmaceuticals. You'll see multivitamins advertised on TV, but the idea that they might do you some good is not as outlandish as the claims for shark cartilage and whatnot.

However, the claim largely seems to be untrue, at least for Americans who are almost universally adequately nourished. Just because a deficiency of a vitamin causes problems doesn't mean that more than enough is better. At one time there were indications from epidemiological studies that antioxidant vitamins might prolong healthy life but the more the issue has been studied, the less likely it seems. In fact, studies as time goes on and studies of higher quality are done, it has started to appear that most supplements may actually be harmful.

You may have heard about a recent publication by Jaakko Murso and colleagues in the Archives of Internal Medicine. This is helpful not only because it reports on new findings from a large-scale epidemiological study, but also because it contains a good review of the current state of knowledge to which this adds. The study included only older white women, so maybe it's different for other categories of Homo sapiens although it's not clear why it would be. And, like most previous studies of this question, it's purely observational. Randomized controlled trials of dietary supplements would be very difficult to do because you need decades of follow up and since they're sold over-the-counter there's really no way to control who takes them and who doesn't.

The difficulty with such studies is that whether people take supplements is not independent of other factors. Maybe people who take them are more health conscious generally, eat better, exercise more, don't smoke, drink only in moderation, yadda yadda. So they appear healthier but it's not because of the supplements. Or maybe people take supplements because they have health problems, so it looks like they're less healthy, but again it's not because of the supplements.

Sigh. All you can do is get as much information about the people as possible and throw it into a multivariate model. If you control for the smoking and obesity and pre-existing illnesses and what-not, you can at least argue that you might have been able to shake out the independent effect of the supplements.

What this study finds is pretty much in line from the picture that has already been emerging. It looks like calcium might be beneficial, but not if taken in excess. It looks like iron supplementation is harmful. This is actually the strongest finding because there is a consistent dose-response relationship, it's been observed in previous studies, and there is a plausible biological explanation for it. Anti-oxidant vitamins, it appears, are more likely to be slightly harmful than they are to be beneficial.

Again, this is all assuming you don't have a nutritional deficiency, but you almost certainly don't. We get everything we need, and usually more, from our diets. Can we absolutely rule out that multi-vitamins and mineral supplements might benefit some people under some circumstances? No, but there's no reason to believe it either. So why spend the money?

But for me, the point is not to give medical advice, which I am not doing. You should talk to your doctor. Rather, the point is that this stuff is heavily advertised, both to old people and to parents of young children (in the form of empty calorie cereal products with a vitamin pill thrown in, as well as actual pills), they're vacuuming up money, and it's essentially a scam. It shouldn't be allowed but the Supreme Court and Congress thinks corporations have a First Amendment right to lie to you. I don't think that was the Original Intent, Justice Roberts.

Not that I care, but obviously, Mormons are not Christians. The distance between the Latter Day Saints and any Christian denomination is vastly greater than the distance between Southern Baptists and Catholics. I don't know how many voters will care either, but this does mean that a major problem facing the Republican Party and the contemporary conservative movement in the U.S. has finally come to the surface. When you base party and movement identification on religious identification and theological commitment, you are building a foundation of rubble.

Faith unites the particular people who subscribe to any given version, but it divides them from everyone else. In the U.S. today, we have a secular society in which this doesn't matter to most people in daily life. Our friendships and workplace relationships generally ignore religious affiliation. There is prejudice among some people against Muslims, obviously, but we're on our way, I think, to ultimately integrating Islam into the tapestry as we have done with Judaism.

In politics, obviously, we have not gotten as far toward true secularism as we have in other spheres. Muslim candidates don't have a chance in most places, Keith Ellison being the exception that proves the rule. We elect Mormons and Jews to office quite commonly nowadays, but it's unclear whether either could be elected president. (I hope we don't get an affirmative answer the hard way, with Mitt Romney.) Atheists, however, have no chance, according to polls. We are disqualified in the eyes of more voters than are Muslims or homosexuals. (Truth.)

But, the Republicans are doing everything in their power to make this situation worse. By claiming that the U.S. is a Christian nation, they not only isolate themselves from non-Christians, they also poke the hornet's nest of who actually counts as a Christian. It works to stir up a certain segment of the electorate as long as those people think you're talking about them and saying they are the special, chosen people who should rule. But it means real trouble when they start quarreling with each other about who exactly is in and who isn't.

There are two outraged constituencies, between which it is essential to distinguish. One is men who consider themselves prostate cancer survivors, often speaking for advocacy groups. They are absolutely convinced that prostate cancer screening saved their lives and ipso facto, if other men are not screened then lives will be lost.

However, it does not follow. What we do know is that they were screened for prostate cancer, they tested positive, they were treated, and they are alive. What we do not know is whether they would be alive if none of the preceding had happened and the answer is, most likely, yes. In fact, based on autopsy findings, about 70% of men over 70 have prostate cancer when they die, and never knew it. These men would very likely have been among them, had they not been screened, and they would also have retained their urinary continence and erectile function.

A few of them would have died of prostate cancer had they not been screened, but more likely, the cancer would have been detected after it became symptomatic and their chances of survival wouldn't have been all that different. And some men who are screened, and undergo treatment as a result, will die sooner than they would have if they weren't treated.

But, men who are so invested in their survivorship and who have dedicated themselves to saving the world from the terrible fate they avoided just aren't going to give that up easily. It's very hard to accept after the fact that such a momentous decision, and the pain and sacrifice it entailed, might have been a mistake. Especially when you are grateful to your doctors and all that. It's just demanding too much cognitive dissonance for them to change their minds.

The second constituency that's howling is of course all those people who make money from prostate cancer screening. Oncologists, radiologists, drug and device companies. No mystery there. Less screening stops the gravy train. All these people will scream and yell but you had best ignore them -- they have an irreducible conflict of interest.

One more piece of good news -- you don't have to let the doctor stick his finger up your ass any more. Just say no. If this causes more guys to show up for appropriate medical care, so much the better.

Thursday, October 06, 2011

Like many people, I find this quite disturbing. I understand that the War on Terra provides certain (what shall I call them?), ah, conceptual challenges to our ordinarily largely thoughtless process of suspending morality in the service of war. In order to make war seem like a morally endowed realm, over the centuries people have developed rules.

For example, it's okay to kill people with projectiles or explosives, but not with poison gas. That seems utterly nonsensical to me but it's extremely important to some people who get quite passionate about the distinction. It's okay to attack a target knowing full well that non-combatant bystanders will be killed or maimed, but it's not okay to intend that they be the target. Again, the distinction largely escapes me, but it's important to some people. Within such constraints, it's fine to kill people, but if you happen to capture them, it's no longer okay. It's also not okay to torture prisoners, or otherwise treat them inhumanely, unless the perpetrator happens to be the United States. And, obviously, you can only kill or maim people using explosives or projectiles if they are combatants of a nation with which the country doing the killing is at war, or happen to be collateral damage of efforts to kill or maim said persons.

In the case of the War on Terra, we have, perhaps perforce, extended the definition of an entity with which we are at war beyond the nation state, but the U.S. has never declared war on Al Qaeda, nor the Taliban, nor is it clear who is and is not a member of either group. Al Qaeda, in particular, is not really an organization but just a label which various people and groups with various degrees of organization and coherence apply to themselves, or have applied to them by others. Osama bin Laden, who U.S. forces recently killed, was a citizen of Saudi Arabia (I believe they revoked his citizenship, leaving him stateless), with which we are not at war; and was killed in Pakistan, with which we are also not at war.

Anwar al Awlaki was a citizen of the United States, with which we are not at war, and was killed in Yemen, with which we are not at war. He also happened to be a citizen of the United States, and therefore constitutionally protected by the following language:

No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger; nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation.

Plain enough. So it would seem that the president of the United States would be exceeding his authority by ordering that a United States citizen be killed, if said person had not been convicted pursuant to due process of law and sentenced to death. In fact the president would be a murderer.

As the Reuters article linked above explains, the president did not issue such an order. In order to "protect" him, such orders are first promulgated "committee of mid-level National Security Council and agency officials. Their recommendations are then sent to the panel of NSC "principals," meaning Cabinet secretaries and intelligence unit chiefs, for approval." All of this is done entirely in secret, without any possibility of judicial review. The president can object, but does not proactively order the person killed.

Evidently I'm supposed to trust these unidentified people to kill only people of whose death I would approve. But why should I? What if the president happened to be someone who appears on the same stage with Bryan Fischer, and agrees that the Bill of Rights does not apply to non-Christians, or homosexuals? Now that we have a functioning death panel, and it's evidently perfectly legal and requires no public justification or accountability of any sort, it's officially available to the next president. Not that I'm down with this one either, but just in case you are, I'm just sayin'.

Wednesday, October 05, 2011

The fact is often bandied about that 1/4 of all Medicare spending is on people in their last year of life. Some people are misled into thinking that this implies more futile and wasteful spending than it really does, because we only know that these people were in their last year of life retrospectively. Generally, doctors are not able to predict how long a person will live, and much of that spending represents appropriate efforts to give people additional years of meaningful life that just didn't work.

Nevertheless, we know that there is a lot of money spent on so-called "heroic" efforts to rescue people who have very low quality of life and/or no hope of living very long, and who do not want the treatment or would not want it if they were able to express their wishes. Furthermore, both the dying and their loved ones generally much prefer to die at home, or failing that in a nursing home, than in a hospital.

It turns out there is huge regional variation in the amount of Medicare spending in the last year of life, which is highly correlated with the percentage of people who die in hospitals. The movement to encourage people to make end-of-life plans, and sign advance directives or appoint a proxy -- a spouse of child, most likely -- empowered to make end-of-life decisions should the person become mentally incompetent -- has increased the number of people making such documents. The number would be even greater, of course, if the proposed Medicare benefit for consultation about end-of-life care had been included in the Patient Protection and Affordable Care Act. Alas, as we all know all too well, Sarah Palin's psychotic screaming about Death Panels put a stop to that.

While advance directives sound like a great idea, unfortunately there has been mixed evidence about whether doctors actually pay attention to them and whether they are effective in reducing unwanted and wasteful expenditures. LH Nicholas and colleagues sort some of this out for us in the new JAMA. The story is a little bit complicated but the main takeaway is fairly simple.

In regions where spending is generally high and more people die in hospitals, treatment limiting advance directives* do seem to make a difference. They reduce average spending by an estimated $5,585 per patient; decrease the probability of dying in a hospital from 47% to 38%; and may reduce the probability of receiving life support by a bit although this difference failed to reach the conventional p
But, the second takeaway is that a) not enough people have advance directives (just under half); and b) they still don't seem to be honored as much as they should be.

Anyway, if you haven't done it yet, please do. It's something we don't want to think about but it is a great favor to your loved ones to have everything clearly understood ahead of time. And to yourself, of course. Your primary care doctor should be able to help you with this even if Medicare won't pay for it.

*You are free, by the way, to make an advance directive calling for everything possible to be done to extend your life, even by one minute, and even if you are a vegetable. However, too few people actually did this to analyze the effect.

Tuesday, October 04, 2011

More than three years ago, before the Lehman debacle, we were already warning of a longstanding pattern of slowing growth: at least since the 1970s, the pace of U.S. growth – especially in GDP and jobs – has been stair-stepping down in successive economic expansions. We expected this pattern to persist in the new economic expansion after the recession ended, and it certainly did. We also pointed out – months before the recession ended – that because the “Great Moderation” of business cycles (from about 1985 to 2007) was now history, the resulting combination of higher cyclical volatility and lower trend growth would virtually dictate an era of more frequent recessions.

So it comes as no surprise to us that, with the latest expansion only a couple of years old, we’re already facing a new recession. Actually, such short expansions are hardly unheard of. From 1799 to 1929, nearly 90% of U.S. expansions lasted three years or less, as did two of the three expansions between 1970 and 1981. In other words, such short expansions are unusual only with respect to recent decades.

It’s important to understand that recession doesn’t mean a bad economy – we’ve had that for years now. It means an economy that keeps worsening, because it’s locked into a vicious cycle. It means that the jobless rate, already above 9%, will go much higher, and the federal budget deficit, already above a trillion dollars, will soar.

Okay, we already have people taking to the streets (and why did it take them so long?) but they don't know what they want, except for times to get better and nihilistic greedheads to stop ripping everybody off. But where will our politics go when it just keeps getting worse? That's really worth worrying about.

Saturday, October 01, 2011

It seems yesterday, Sept. 30, was Blasphemy Day. I don't know how I could have left that off my calendar.

Well, okay, I don't really need a special day for it. But as much as I enjoy blaspheming, the challenge is that the more intensely religious a person is, the more likely that person is to commit blasphemy. It's an almost perfect correlation. If I say Jesus is the son of God, I'm committing blasphemy as far as every Muslim, Jew and Zoroastrian is concerned. If I say Muhammad is God's prophet, I've committed blasphemy in every Christian dominion. If I say Rebe Menachem Scheerson was the Messiah and he will be reincarnated . . . well, you get the idea.

I don't go around saying stuff like that. On the other hand my occasional references to the 4.65 billion year antiquity of the earth, the common ancestry of humans and slime molds (I was about to say Chimpanzees but that's too obvious), or the dependence of consciousness on its biological substrate are no doubt blasphemous to some people, but each of these are facts that I touch upon only when they come up in some exigent context. I don't just ritually repeat them as a periodic duty. So I'll pass on Blasphemy Day after all. It's just superfluous.